Job Summary:
Responsible for timely billing and follow up for all acute care Medicare claims according to State and Federal regulations. Reviews and resolves credit balances. Works all denials and or rejections from the billing work ques timely. Submits accurate contractual adjustments and proper documents each account. Responsible for inputting accurate data into excel spreadsheets. Pull data for audits and assist with special projects and or backlogs within the office. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
Pharmacy Biller/Collector-
Responsible for timely billing and follow up for all Part “D”, Sub-Acute/SNF patients. Works all denials and or rejections in a timely manner. Works incoming correspondence. Works closely with the Pharmacy departments relating to the drugs and formulas. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.
Essential Functions:
- Knows how to download CMS/Epremise system daily or as needed.
- Monitors & processes credit balances for refunds and transfers in accordance with department procedures.
- Processes daily bills via CMS/Epremise system.
- Process claims and bills to payors through bill editor in accordance with department procedures.
- Knowledge in printing the Remittance Advices.
- Works on denial accounts daily or as needed.
- Works on daily rejection daily or as needed.
- Works on daily mail and correspondence.
- Responsible for working off the work ques and clearing ticklers efficiently.
- Maintains quality control on all accounts for correct plan ID’s and financial class. Updates system with appropriate changes.
- Sends requests to ancillary departments for reports needed to bill claims in a timely manner.
- Responsible to keep current with updates and changes within the Medicare m via CMS website.
- Responsible to retrieve any patient information from the HBF system.
- Processes daily contractual adjustments. & calculates payment and contractual adjustment according to expected reimbursement.
- Works and resolves aged accounts.
- Identifies under and over payments.
- Ensures each account has detailed documentation as required by the department procedures.
- Meets productivity requirements daily.
- Provides Medicare RA’s to cross over biller.
- Prepares credit balance reporting every quarter to Medicare.
- Demonstrates ability to reach decisions takes appropriate action and follow through within scope of responsibility, as defined by job description.
- Processes secondary billing and transfers in accordance with department procedures.
- Performs all other duties and special projects as assigned.
- Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
- Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
- Completes and attends monthly training assigned.
Pharmacy Biller/Collector-
- Prepare Pharmacy billing forms for all sub-acute/SNF patients.
- Create and maintain patient files for all information and billing records.
- Prepare and update Drug Order Reference sheets for all sub-acute/SNF patients.
- Obtain Drug Profile for all affected patients from the pharmacy and reconcile with patient records for billing purposes.
- Obtain, update, and reconcile patient census including discharges and admissions with all billing records.
- Obtain and maintain current billing manuals and books.
- Review and reconcile Hospital Drug Formulary with actual items on pharmacy stock to ensure accurate billing of utilized medications.
- Obtain and maintain current prescribing physician’s information including license #s, DEA #s, Telephone contact information etc.
- Prepare and update Drug Price Lists.
- Prepare and perform monthly update of Medi-Cal Drug Provider and policy manual (part 1 & 2)
- Complete and transmit electronic billing for Medi-Cal drug approved medications used by SNF/sub-acute care patients.
- Maintain accurate records of all billings in individual patient files for any review purposes.
- Work with the Pharmacist to complete TAR's for all required drugs utilized by patients.
- Fill out correctly and submit by mail all manual/hard copy drug/pharmacy billing to Medi-Cal
- Follow up with Medi-Cal office on billing issues to ensure accurate reimbursements.
- Obtain, review, and maintain copies of the remittance advice details and follow-up on any inaccuracies with the Medi-Cal office for resolutions.
- Create and maintain records of total daily billing amounts.
- Create and update Annual Billing totals for each facility.
- Communicate changes in patient/Medi-Cal drug coverage with Pharmacist.
- Obtain supervisory approval to attend relevant posted educational billing seminars to keep up with the current trends.
- Resolve DUR Medi-Cal inquiries with the Pharmacist for affected drugs/ patients prior to re-submission of relevant billings.
- Provide Pharmacy check-write to business office Director every Monday.
- Performs all other duties and special projects as assigned.
- Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
- Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
- Completes and attends monthly training assigned.
Behavioral Standards:
- Exhibits customer and service-oriented behaviors in everyday work interactions.
- Demonstrates a courteous and respectful attitude to internal workforce and external customers.
- Communicates accurately and appropriately.
- Works well and efficiently under minimal supervision.
- Handles difficult situations in a discreet and professional manner.
- Is adaptable to changes in assignments and priorities.
Communication/Knowledge:
- Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.
- Provides accurate and timely written and verbal communication of information in a manner that is understood by all.
- Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal outcome.
- Able to use IT systems in an accurate and proficient manner.
Collaboration/Teamwork:
- Contributes toward effective, positive working relationships with internal and external colleagues.
- Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.
Qualifications:/Experience:
- At least two (2) to three (3) years of current experience in an acute care hospital setting, preferred.
- Computer skills preferred.
